It will be most important for the nurse to check pulse oximetry for which of these patients?
a. A patient with emphysema and a respiratory rate of 16
b. A patient with massive obesity who is refusing to get out of bed
...
It will be most important for the nurse to check pulse oximetry for which of these patients?
a. A patient with emphysema and a respiratory rate of 16
b. A patient with massive obesity who is refusing to get out of bed
c. A patient with pneumonia who has just been admitted to the unit
d. A patient who has just received morphine sulfate for postoperative pain - ✔✔C
Rationale: Hypoxemia and hypoxemic respiratory failure are caused by disorders that interfere with the
transfer of oxygen into the blood, such as pneumonia. The other listed disorders are more likely to cause
problems with hypercapnia because of ventilatory failure.
Cognitive Level: Application Text Reference: pp. 1799-1800
Nursing Process: Assessment NCLEX: Physiological Integrity
A nurse working in the ED is caring for a pt following an acute chest trauma. Which of the following
findings indicates to the nurse the client is possible experiencing a tension pneumothorax?
a. Collapsed neck veins on the affected side
b. Collapsed neck veins on the unaffected side
c. Tracheal deviation to the affected side
d. Tracheal deviation to the unaffected side - ✔✔d. Tracheal deviation to the unaffected side
* A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and
forcing the trachea to deviate to the unaffected side
* DISTENDED neck veins are an expected finding of a tension pneumothoraxThe nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency
department has
a. chest trauma and multiple rib fractures.
b. carbon monoxide poisoning after a house fire.
c. left-sided ventricular failure and acute pulmonary edema.
d. tachypnea and acute respiratory distress syndrome (ARDS). - ✔✔A
Rationale: Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma when rib
fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning, acute pulmonary edema,
and ARDS are more commonly associated with hypoxemia.
Cognitive Level: Application Text Reference: p. 1800
Nursing Process: Assessment NCLEX: Physiological Integrity
A nurse is assisting the provider who is performing a thoracentesis at the bedside of a pt. Which of the
following actions should the nurse take?
Select all that apply
a. Wear goggles and mask during the procedure
b. Cleanse the procedure area with an antiseptic solution
c. Instruct the client to take deep breaths through the procedure
d. Position the client laterally on the affected side before the procedure
e. Apply pressure to the site after the procedure - ✔✔A B E
a. Wear goggles and mask during the procedure
* reduces the risk of exposure to pleural fluid
b. Cleanse the procedure area with an antiseptic solution* antiseptics are antimicrobial substances that are applied to living skin/tissue to reduce risk of infection
e. Apply pressure to the site after the procedure
* decreases risk of bleeding at procedure site
The nurse should instruct the pt to remain as still as possible during to reduce the risk of puncturing the
pleura or lung.
The pt should be positioned in a sitting position leaning over the bedside table or laterally on the
UNAFFECTED side to promote access to the site and encourage draining of pleural fluid
When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk of
poor oxygenation because of
a. too-rapid movement of blood flow through the pulmonary blood vessels.
b. incomplete filling of the alveoli with air because of reduced respiratory ability.
c. decreased transfer of oxygen into the blood because of thickening of the alveoli.
d. mismatch between lung ventilation and blood flow through the blood vessels of the lung
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